Middleburg Borough 13 North Main Street Middleburg, PA 17842 570-837-2533 Complaint Form Resident of Middleburg! Employeel Name: Address: City/State: Phone# #: Date of Report Complaint Against: Date of Incident / Occurrence: Time of Incident / Occurrence: Location of Incident/Ocourence: Nature of Complaint: (Cover: who, what, when, where, why) How Received: Letter Received Fax How Handled: Letter Sent Phone Visit Fax Sent Phone In Person Refer to Other Agency *NOTICE* Under Section 4904 oft the PA Crimes Code, unsworn falsification to authorities; a person commits a misdemeanor oft the third degree ifhe/she makes av writtens statement which! he/she does not believe to be true. Received Date: Received By: Complaining Party Form: Borough Complaint 2018